List names and phone number of people who you authorize to pickup your child (other than you)

Emergency Medical Information

Permission is given to One With Heart for the following:
In an emergency, One With Heart has my permission to obtain medical treatment for my child, call an ambulance or transport my child to any available physician or hospital at my expense, with the following restrictions (if applicable)
My child may be given medication. I understand the Medical Authorization form must be completed and signed prior to administering. I understand I must clearly communicate any medication administration instructions and permission to OWH staff prior to camp.
My child may participate in One With Heart Poekoelan Center field trips. I understand van or public transportation may be used.
My child may participate in swimming or other water activities.
My child may be photographed for without any personal identifiers in marketing materials and media promoting the school.

Child's Physician *

Physician's Address

Physician's Phone *

Physician's Phone

(###)

###

####

Allergy Information *

Date of last Tetanus *

Child's Dentist

Dentist's Address

Dentist's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Hospital

Health Insurance Company and Phone Number *

Parent or Legal Guardian Signature *

How did you hear about us? (Facebook, Google, Yelp, Etc) *

GET UPDATES AND INFORMATION ABOUT ONE WITH HEART BY SIGNING UP FOR THE E-NEWSLETTER